Staring Down Dragons

Every crisis chooses its heroes. The heroes do not volunteer for the role. Brave souls do not rush to the front line to save us. The heroes, ordinary folk until now, are plucked from their previous lives without warning, whether they are willing or not, whether they are ready or not. In this crisis, there are many heroes (see Heroes in Masks with Mops). Everyone who shows up for their shift—whether they be nurse, houseman, security guard, food service worker, physician, or one of the countless other individuals needed to care for the tsunami of sick COVID-19 patients overwhelming our hospitals–is truly performing an act of courage each and every day. The heroes for the history books, though, the heroes who will be remembered by their colleagues long after this plague passes, are the anesthesiologists, nurse anesthetists, respiratory therapists, and ENT surgeons who find themselves staring down this monster every day–some many, many times on a really bad day. These are the special people whom we will always remember with an admiring nod and a tear of appreciation.nurse-anesthetist-vs-anesthesiologist.jpg.5c6db5df59cf2f07619cd04bbc39f0c1

The AIDS epidemic was the last plague that truly threatened US medical workers. While Ebola and H1N1 challenged us, neither of these crises presented a general threat to the health of our practitioners in this country. AIDS, however, during the terrible years of the late Eighties and early Nineties, killed our practitioners as well as our patients. We forget now, because of brilliant scientists like David Ho and countless others, who have given us effective treatments for HIV. But for several years, AIDS actually was the leading cause of death of people under age 40 in this country, the only time any disease displaced trauma from the top of the list. AIDS killed EVERYBODY it infected. And if the medical professional caring for the critically ill AIDS patient suffered a significant exposure, there was a definite possibility that they would die–horribly, because everyone with AIDS in those days died, horribly. Whole wards were filled with young people dying, horribly. Many AIDS patients developed severe intra-abdominal crises that required urgent surgical intervention. Surgery on these patients was fraught with the possibility of killing the surgeon, because these patients generally had extremely high viral loads at the time of their surgical crisis. This was the first time in memory when we had a national discussion about whether a doctor or nurse was morally obligated to care for an ill patient.

Doctors and nurses were dying. General surgeons, resident surgeons in training, orthopedic surgeons, surgical techs, and scrub nurses were at risk from needle sticks, blood splatters, intra-operative incidents of all kinds; significant or seemingly mundane, but now mortal injuries. Some surgeons refused to operate on HIV positive patients, hiding behind the argument that the patients were all dying anyway. This left the rest of us scrubbing on more and more of these dangerous procedures as others subtly deferred consults. Scrub techs and nurses willing to operate in dangerous conditions were increasingly called upon to fill in for those who declined. NY state entertained a law requiring surgeons who seroconverted to notify all patients of their status in the never-proven concern that a patient might contract the disease from the practitioner. So we stopped getting tested after every needle-stick, we even stopped donating blood, because we were not only risking our health, but also our ability to practice. It was a double-edged sword, with both edges pointed toward the practitioner. We stopped telling our spouses and colleagues about every torn glove or needle stick during an AIDS patient operation, because we stopped thinking about it as soon as we left the OR. But we kept operating on HIV patients, trying blunt-tip needles, extra-thick latex gloves, even chain-mail gloves—none of which helped in the least. Be careful, assume every patient is positive, universal precautions, we were told—all of it went right out the window with the next trauma patient in shock.

This plague has picked a different hero. Now, the riskiest moment for the health care practitioner is the intubation of a deteriorating COVID infected patient. In every hospital, anesthesiologists, anesthetists, and respiratory therapists, as well as many emergency medicine physicians and ENT surgeons, are placing their heads in the maw of the dragon as they insert an endotracheal tube needed to save a patient’s life. There is not a more dangerous maneuver in our current practice. Even worse than the surgeon operating on the AIDS patient, our modern knights staring down this dragon are not protected with chain-mail gloves, cannot even see the enemy, because it attacks—not in a spray of blood or with the pain of an errant needle—but in an invisible miasma. The risk of each individual intervention may be less, but the anxiety so much greater, as no one knows as they pull off their mask if, on this occasion, the dragon’s breath got past their shield. There is no choice but to take a deep breath, say a little prayer, and go on to the next patient.

When our anesthesiologists, anesthetists, ER docs, and respiratory therapists applied for training, none of them took a moment to ask themselves if they were brave enough to do this work. The job interview didn’t include a question about courage. No one signed up for this. They just do the work we need them to do to save our lives. When this is finally over, we will not forget that.

Heroes in Masks with Mops

The physicians and nurses facing the onslaught of this pandemic are undoubtedly heroes. We salute them for leaving their homes and families every day to face the risk of personal illness and death. Their bravery is an inspiration. That bravery is a product of the oath that each swears upon entering this profession. There are others in this struggle, however. Others who never swore an oath to use their skills to care for the sick and injured. Others who are every bit as critical to these efforts, but who are not receiving accolades and applause as they make their way to hospitals every day, to work another shift at great personal risk. I am speaking of the janitors and housemen and women who work in our hospitals all day, every day.

These brave individuals serve an indispensable role in caring for patients and keeping the medical system working. They transport the patients to the ICU’s, and in so doing, are exposed to the same risks as the treating physicians and nurses. During the painful learning process of caring for the sickest of the COVID-19 patients, it was discovered that the technique of prone ventilation, in which the patient is positioned on their belly while on a ventilator periodically every day, is the only consistently effective therapeutic intervention so far. But this treatment requires the careful repositioning of a sedated patient in critical condition, a process that requires a team of nurses, physicians, and other health care workers to effect safely. Those other health care workers are often Physician Assistants, or Surgical Techs displaced from the now-idle operating suite, and Housemen and women. This oft-repeated therapeutic maneuver puts all members at an equal risk of infection. And while nurses and physicians, PA’s and NP’s are carefully trained and experienced in how to minimize their risks, these other critical team members have–until this moment–not prepared professionally for this effort. Nonetheless, we expect this, and much more, of them. They have stepped into the battle without hesitation.

Janitors also are unsung heroes in this crisis. They are required, just as the physicians and nurses, to don PPE and masks to perform the critical duties of cleaning the rooms and care spaces of the contagion which is pervasive in their work. Our janitors are no less courageous in their efforts. Indeed, maybe more so, as the physicians and nurses are almost always working as a team, with particular monitoring for the proper removal of protective garb and other concerns to minimize risk. Janitors, however, are often working on their own, with no such assistance. Every ICU room, every ventilator, every ER bay, must be cleansed and prepared, else risk injury of the next patient. Without the critical services of the janitors, the system cannot provide care.

These brave health care professionals, the janitors and housemen and women in every hospital, are working just as hard and at just as great a risk, as our physicians and nurses. They never swore an oath. They don’t get the same benefits, or the same pay, or the same accolades. But they deserve at least as much of our gratitude.

 

How science works

Yes, this (in anticipation of my upcoming series of blog rants on the state of clinical medical publications):

The Devil's Neuroscientist

My previous post discussed the myths surrounding the “replication crisis” in psychology/neuroscience research. As usual, it became way too long and I didn’t even cover several additional points I wanted to mention. I will leave most of these for a later post in which I will speculate about why failed replications, papers about incorrect/questionable procedures, and other actions by the Holy Warriors for Research Truth cause such a lot of bad blood. I will try to be quick in that one or split it up into parts. Before I can get around to this though, let me briefly (and I am really trying this time!) have a short intermission with practical examples of the largely theoretical and philosophical arguments I made in previous posts.

Science is self-correcting

I’ve said it before but it deserves saying again. Science self-corrects, no matter how much the Crusaders want to whine and claim that…

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The Contenders – Lewis Hamilton

For my fellow F1 followers, the following (and no, I won’t be reblogging anything about Rosberg):

The Buxton Blog

GP2 Testing, February 2006 GP2 Media Service GP2 Testing, February 2006
GP2 Media Service

I’d expected him to look older. I suppose its only natural with someone you’d been reading about for years, but he’d been such a constant part of the motorsport landscape for such a long time that I’d imagined he’d already be the finished article. He’d been a mini-megastar in England since his karting days. Even as a child I remember seeing his face on TV, on the news, on ITV’s karting show with DJ David ‘Kid’ Jensen, Blue Peter, through the pages of Autosport and Motoring News. He was a future world champion. That’s what we’d always been told. That’s what we’d always believed. And here he was, this future F1 superstar. I’d expected him to be taller. I’d expected him to be broader… I’d expected him to look older.

But there he stood on the pitwall in his ASM F3 overalls, a…

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No country for young women: Honour crimes and infanticide in Ireland

While I do not agree with every point made by this author, she certainly brings a more cogent viewpoint to this most recent horrific discovery than has been presented in the press to date.

Feminist Ire

magdalene

When I was in first year in secondary school in 1997, a girl in the year above me was pregnant. She was 14. The only people who I ever heard say anything negative about her were a group of older girls who wore their tiny feet “pro-life” pins on their uniforms with pride. They slagged her behind her back, and said she would be a bad mother. They positioned themselves as the morally superior ones who cared for the baby, but not the unmarried mother. They are the remnants of an Ireland, a quasi-clerical fascist state, that we’d like to believe is in the past, but still lingers on.

The news broke last week of a septic tank filled with the remains of 796 children and babies in Galway. The remains were accumulated from the years 1925 to 1961 and a common cause of death was malnutrition and preventable disease…

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Anti-Homeless Spikes. What the actual fuck?

As usual, the Brits are a step ahead of us. Here’s to not following them down this road.

Thought Scratchings

homelessspikes

I wasn’t going to comment on this, because I thought, it’s obviously horrible.  I thought no human could possibly convince themselves that putting spikes beneath other human beings is an act of mercy. I thought not even the most cold-hearted intellectuals (you know, the ones with hooks for faces, and scars that run across their souls) could see spikes on the ground, and reach the conclusion that they are for the benefit of the homeless.

I was wrong.

There are some in this wonderful world of the armchair genius who believe that putting spikes under the mentally ill is a good thing. They think that if people can’t sleep where they usually do, they will be encouraged to stop sleeping rough. Like, it’s a choice. Imagine Homeless Doug. Doug often sleeps in doorway 34. Doorway 34 isn’t much. But it’s all Doug has. One night Doug returns to…

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